Wiki 99495 and 99496Transitional Care Management Services

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Hello,

I was wondering if anyone can provide any information regarding Primary Care Physicians billing the Transitional Care Management Services 99495 and 99496.

What does this type of service look like at the PCP office?
What does the documentation look like?
How much is reimbursed for these codes?

Any information is helpful

Thank you

Dabs
 
Question

I reviewed the discussion link and it was helpful. I do have another question that I did not see answered on the discussion log.

Our clinics are integrated care. We have both medical and behavioral providers. We also have case managers who bill the HCPCS case management codes T1016 and now they are following up with clients regarding any behavioral and medical issues/concerns.

If our providers are billing the TCM codes, can our staff continue to bill for case management follow up? I can't seem to find any information on this being a billing limitation.

Any advice or information will be helpful

Thanks

Dabs
 
Many practices are using case managers to conduct the clinical staff work associated with transitional care management. However, the physician reporting TCM is responsible for the patient's overall care and supervision of the clinical staff services are integral to the TCM service. Per CPT, "The reporting individual provides or oversees the management and/or coordination of services, as needed, for all medical conditions, psychosocial needs and activity of daily living support by providing first contact and continuous access."

This comprehensive nature of TCM would appear to prohibit separate reporting of case management services. Payer guidance and coverage of each service may vary. NCCI edits are likely not helpful given that T1016 is not valued in the Medicare Physician Fee Schedule but private payers and Medicaid plans may establish edits.
 
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